Clinical Briefs

Carrie Morantz

Brian Torrey

Am Fam Physician. 2003 May 1;67(9):2018-2022.

CDC Guidelines on SARS

The Centers for Disease Control and Prevention (CDC) has issued guidelines and recommendations on diagnosing and treating patients with severe acute respiratory syndrome (SARS), and on preventing transmission of SARS in the health care setting. The guidelines and recommendations are available atwww.cdc.gov/ncidod/sars, and are evolving as more is learned about the syndrome and effective treatments.

SARS was defined on March 22, 2003, as a respiratory illness of unknown etiology with onset since February 1, 2003, with the following criteria:

Travel within 10 days of onset of symptoms to an area with suspected or documented community transmission of SARS (Toronto, Canada; Hong Kong Special Administrative Region and Guangdong province, China; Hanoi, Vietnam; and Singapore), excluding areas with secondary cases limited to health care workers or direct household contacts. Or,

Close contact within 10 days of onset of symptoms with either a person with a respiratory illness and travel to a SARS area, or a person under investigation or suspected of having SARS. Close contact is defined as having cared for, having lived with, or having had direct contact with respiratory secretions and/or body fluids of a patient suspected of having SARS.

Suspected cases with either radiographic evidence of pneumonia or respiratory distress syndrome, or evidence of unexplained respiratory distress syndrome by autopsy, are designated “probable” cases by the World Health Organization (WHO) case definition.

The incubation period for SARS is typically two to seven days; however, isolated reports have suggested an incubation period as long as 10 days. The illness usually begins with a fever. Other signs and symptoms include chills, headache, general feeling of discomfort, and body aches. Some people also experience mild respiratory symptoms at the onset.

As of April 16, the CDC recommends patients with SARS receive the same treatment that would be used for any patient with serious community-acquired atypical pneumonia of unknown cause.

Several treatment regimens have been used for patients with SARS, but there is insufficient information at this time to determine if they have had a beneficial effect. Reported therapeutic regimens have included antibiotics to presumptively treat known bacterial agents of atypical pneumonia. Therapy also has included antiviral agents such as oseltamivir or ribavirin. Steroids also have been administered orally or intravenously to patients in combination with ribavirin and other antimicrobials.

The CDC has sequenced the genome for the coronavirus believed to be responsible for the global epidemic of SARS, and found that the SARS coronavirus is a previously unrecognized coronavirus. This data will have an impact on efforts to develop new diagnostic tests, antiviral agents, and vaccines. However, the treatment recommendations have not been changed. Various antiviral drugs are being tested for their effectiveness against SARS.

A patient information handout on SARS written for parents is available atwww.familydoctor.org. The handout addresses risk factors and commonly asked questions.

Hepatitis Infections in Correctional Settings

The Centers for Disease Control and Prevention (CDC) has issued recommendations to prevent and control viral hepatitis infections in correctional settings. The recommendations appeared in the January 24, 2003 issue of the CDC's Morbidity and Mortality Weekly Report, Recommendations and Reports, and are available online atwww.cdc.gov/mmwr.

Persons who spend time in jails, prisons, and juvenile institutions have an increased risk of infectious disease, including high rates of infections with hepatitis B virus (HBV) and hepatitis C virus (HCV). They also have high rates of certain risk behaviors, such as the use of injectable drugs, which expose them to infections with HBV and HCV.

The recommendations address incarcerated juveniles and adults, and cover topics including identification, reporting, and investigation of cases of acute viral hepatitis; hepatitis A and hepatitis B immunization; testing to identify persons infected with chronic HBV and HCV infection, or immunity to infections; counseling to prevent HCV infection and its consequences; medical evaluation of inmates with HBV and HCV infection; and health education. The recommendations also address the protection of correctional officers from hepatitis infection.

Key recommendations include the following:

All persons under correctional jurisdiction are at higher risk of a hepatitis infection, and should therefore be vaccinated against HBV, unless they have been previously vaccinated or have been previously infected with HBV and presumably are immune to reinfection.

Medical evaluation in a correctional facility should include a behavior risk assessment and inmates with risk factors should be tested for HCV infection.

Inmates who test positive for HCV should be evaluated for chronic infection and the extent of liver disease.

Inmates with chronic HCV should be evaluated for antiviral treatment, which should be considered based on criteria developed by each jurisdiction and incorporate current treatment guidelines.

Education regarding the prevention of viral hepatitis should be made part of health education programs for all correctional facility inmates.

Implementation of these recommendations may reduce transmission of hepatitis among adults at risk in both correctional facilities and the outside community. It is estimated that 12 to 15 percent of all Americans with chronic HBV and 39 percent of those with HCV infections were released from a correctional facility during the previous year. Additional information about hepatitis is available at the CDC's Web site,www.cdc.gov/hepatitis.

AHRQ Announces New Web-Based Medical Journal

The Agency for Healthcare Research and Quality (AHRQ) has started a new monthly peer-reviewed, Web-based medical journal that showcases patient safety lessons drawn from actual cases of medical errors. “AHRQ WebM&M (Morbidity and Mortality Rounds on the Web)” is available at webmm.ahrq.gov. The journal seeks to educate health care professionals about medical errors in a blame-free environment.

Clinicians routinely hold morbidity and mortality conferences to discuss specific cases that raise issues regarding medical errors and quality improvement. Every month, five cases of medical errors and patient safety problems (one each in medicine, surgery/anesthesiology, obstetrics-gynecology, pediatrics, and other fields including psychiatry, emergency medicine, and radiology) will be posted along with commentaries from experts and a forum for readers' comments. Each month, one of the five cases will be expanded into an interactive learning module featuring readers' polls, quizzes, and other elements offering continuing medical education credits. Cases are limited to near misses or those that involve no permanent harm.

Recommendations for Preventing Medication Errors in Children

Medication errors occur in hospitals across the country, usually without harm. However, when medication errors involve pediatric patients, the consequences can be far more devastating. To help improve the safety of young patients, the United States Pharmacopeia (USP) has released separate recommendations for health care professionals and parents for preventing medication errors in children. The recommendations are available online atwww.usp.org.

Medication errors in children can occur when a decimal point is misplaced in a dose, or an incorrect weight conversion from pounds to kilograms is made. Physicians and other health care professionals must consider a child's age, weight, medication dosing frequency, and other factors to help ensure the safety of young patients. The USP recommendations for health care professionals include the following:

Dosage forms and/or preparations that are compounded, prepared in serial dilutions, and/or extensively manipulated should be prepared in the pharmacy and verified by a pharmacist. Where possible, a second health care professional familiar with dilutions and compounding should verify the product preparation and labeling.

Policies and procedures should be developed and implemented when automated dispensing machines are being used for pediatric medications, including double independent verification of medications loaded into the machines and the inability to override system safeguards.

When possible, medications should be prepared and dispensed as “unit-dose” containers for all pediatric medications in all health care facilities.

Liquid medications dispensed in the outpatient setting should be dispensed with appropriate measuring devices and instructions for use. When possible, use of the measuring device should be demonstrated to the patient/caregiver.

The prescription order should be reviewed by a health care professional for appropriateness and dosage accuracy using the patient's weight, age, and other appropriate dose indicator(s) before dispensing and administering each dose and/or refill for pediatric patients.

The patient's weight, age, and other appropriate dose indicator(s) should be available and clearly identified on all prescriptions and orders before the dose is dispensed and administered.

Wherever possible, pediatric dosages should be calculated by a validated computer algorithm as part of an integrated medication order entry system. Calculations, whether computerized or manual, should be independently double-checked by a pharmacist and signed off by at least one other licensed health care professional to confirm accuracy.

Abbreviations, acronyms, and symbols used throughout an organization should be standardized and readily available. A list of abbreviations, acronyms, and symbols that should not be used also should be available.

To prevent 10-fold overdoses, a terminal or trailing zero should never be used after a decimal. A leading zero should always precede a decimal expression of less than one.

In all health care settings, patients, parents, and/or caregivers should be provided verbal and written information about the pediatric patient's medication, the common side effects, and the adverse events that should be reported to a health care professional.

The USP recommendations for parents include the following:

On admittance to the hospital, provide the attending physician or nurse with an up-to-date list of all medicines (prescription and over-the-counter) and dietary supplements that your child is taking.

Make sure your child's physician is aware of any allergies the child may have. For life-threatening allergies, your child should wear a MedicAlert bracelet at all times.

For purposes of preparing appropriate dosages of medicines, the child's weight in pounds must be divided by 2.2 to convert his or her weight into kilograms. Be aware of this calculation and/or your child's weight in kilograms, and reconfirm the correct dosage with your child's physician if you have concerns.

Be sure that you are provided with verbal and written information about your child's medications, the common side effects, and the adverse events that should be reported to your child's physician.

Pay close attention to how your child is feeling while in the hospital. Notify the physician immediately if you notice any negative side effects from the administered medications, such as sudden difficulty in swallowing or breathing.

If your child is given a liquid medication to take after release from the hospital, be sure you are provided with an appropriate measuring device and instructions to ensure proper medication doses.

In case of an emergency, be sure that your child's school has a list of any medical conditions or allergies your child may have.

In December 2002, USP released an analysis of medication errors captured in 2001 by MEDMARX, the anonymous, national reporting database operated by USP. This third annual report, “Summary of Information Submitted to MEDMARX in the Year 2001: A Human Factors Approach to Medication Errors,” is the most comprehensive compilation of medication error data submitted by hospitals and health systems nationwide.

Of the 105,603 errors documented by MEDMARX, 3,361 errors, or 3.2 percent of total errors, involved pediatric populations. Although the vast majority of errors were corrected before causing harm to the patient, 190 errors, or 5.7 percent of total errors, resulted in patient injury. Of this number, 156 resulted in temporary harm to the patient and required intervention, 31 required initial or prolonged hospitalization, one required intervention to sustain life, and two errors resulted in a patient's death. The full report is available online atwww.usp.org.